Establishment and effectiveness evaluation of a chronic obstructive pulmonary disease chain management model in the context of medical consortium

doi:10.19983/j.issn.2096-8493.20250007

Abstract

Abstract:

Objective: To establish hospital-community-family chain management model for chronic obstructive pulmonary disease (COPD) patients based on a medical consortium and evaluate its application outcomes. Methods: A total of 166 elderly COPD patients treated at The Second People’s Hospital of Changshu from April to September 2022 were selected as study subjects through purposive sampling. All participants were informed about both the COPD hospital-community-family chain management model and the conventional management model. Eighty patients receiving the chain management model were assigned to the observation group and underwent combined online and offline interventions until 6 months post-discharge, while 86 patients under conventional management were assigned to the control group and received routine care and follow-up. Differences between the two groups were compared using the Chronic Disease Self-Efficacy Scale (CDSES), the Medication Adherence Questionnaire (MAQ), and the abbreviated version of the Quality of Life Assessment Scale (QOL-AS). Results: After the intervention, the CDSES score of the observation group was (56.15±3.66), significantly higher than in the control group’s (41.93±1.21), and the difference was statistically significant (t=2.656, P<0.001). At 6 months post-discharge, 63.8% (51/80) of the observation group showed good medication adherence, higher than 45.3% (39/86) in the control group (χ²=3.871, P<0.001). The observation group also achieved a higher QOL-AS score (69.35±3.96) than that of the control group (51.48±2.14), and the difference was statistically significant (t=1192.273, P<0.001). Conclusion: A well-designed chain management model for COPD patients, combined with continuous homogeneous management, can effectively enhances self-management efficacy, medication adherence, and quality of life in COPD patients.

Key words: Pulmonary disease, chronic obstructive, Patient care management, Models, nursing, Nursing evaluation research

CLC Number:

R563
R473.5

Li Qin, Li Muchen, Wang Mengzhou, Zhang Qiuping, Zhao Yungen. Establishment and effectiveness evaluation of a chronic obstructive pulmonary disease chain management model in the context of medical consortium[J]. Journal of Tuberculosis and Lung Disease , 2025, 6(2): 210-216. doi: 10.19983/j.issn.2096-8493.20250007

Figures/Tables 4

References 19

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资料	观察组(80例)	对照组(86例)	统计检验值	P值
性别			χ²=0.017	0.895
男性	63(78.8)	67(77.9)
女性	17(21.2)	19(22.1)
年龄组(岁)			χ²=19.257	<0.001
60~	21(26.3)	21(24.4)
70~	41(51.3)	42(48.8)
≥80	18(22.4)	23(26.8)
居住地			χ²=21.112	0.007
乡镇	25(31.3)	24(27.9)
农村	40(50.0)	41(47.7)
城市	15(18.7)	21(24.4)
文化程度			Z=―0.183	0.855
文盲	13(16.2)	17(19.8)
小学	41(51.3)	40(46.5)
初中	20(25.0)	23(26.7)
高中或中专	5(6.2)	4(4.7)
大专及以上	1(1.3)	2(2.3)
职业状态			χ²=1.122	0.571
在职	5(6.2)	7(8.2)
退休	56(70.0)	64(74.4)
无职业	19(23.8)	15(17.4)
家庭人均月收入(元)			Z=―0.122	0.903
<3000	3(3.7)	1(1.2)
3000~4999	24(30.0)	28(32.6)
≥5000	53(66.3)	57(66.2)
照顾情况			χ²=0.462	0.794
家人照顾	45(56.2)	49(57.0)
护工照顾	11(13.8)	9(10.5)
无人照顾	24(30.0)	28(32.5)
病程(年)			Z=―0.631	0.528
<5	27(33.8)	25(29.1)
5~	32(40.0)	36(41.8)
>10	21(26.2)	25(29.1)
是否合并其他疾病			χ²=0.105	0.746
是	53(66.2)	59(68.6)
否	27(33.8)	27(31.4)

组别	例数	症状管理自我效能		疾病共性管理自我效能		总分
组别	例数	干预前	干预后	干预前	干预后	干预前	干预后
观察组	80	23.99±5.68	35.62±2.97	13.08±4.57	16.34±1.21	44.06±7.64	56.15±3.66
对照组	86	23.87±3.72	34.64±3.91	14.11±2.65	15.24±3.01	44.04±3.69	41.93±1.21
t值		0.542	3.259	0.153	3.096	0.095	2.656
P值		0.591	<0.001	0.879	<0.001	0.925	<0.001

组别	例数	出院后1个月		出院后3个月		出院后6个月
组别	例数	依从	不依从	依从	不依从	依从	不依从
观察组	80	61(76.2)	19(23.8)	57(71.2)	23(28.8)	51(63.8)	29(36.2)
对照组	86	63(73.3)	23(26.7)	51(59.3)	35(40.7)	39(45.3)	47(54.7)
χ²值		0.197		0.717		3.871
P值		0.657		0.039		<0.001

组别	例数	躯体领域	心理领域	社会关系领域	环境领域	总分
观察组	80	15.24±2.73	13.89±1.86	13.93±1.91	12.14±2.06	69.35±3.96
对照组	86	10.83±2.41	9.42±2.35	12.53±2.79	10.03±3.52	51.48±2.14
t值		11.051	13.522	3.745	2.340	1192.273
P值		<0.001	<0.001	<0.001	4.669	<0.001